Maternal Mortality Remains a Serious Problem

Racial disparities part of the issue, experts say

WASHINGTON -- More efforts need to be made to reduce maternal mortality in the U.S., where the rate is increasing in contrast to most other countries, several speakers said at a briefing here sponsored by the American College of Obstetricians and Gynecologists (ACOG).

"A recent World Health Organization report found that 157 out of 183 countries had reductions in maternal mortality from 2000 to 2013," Marian MacDorman, PhD, of the Maryland Population Research Center, in College Park, said at Friday's briefing. "In contrast, there was a 27% increase in maternal mortality for 48 states and the District of Columbia combined. Clearly, the U.S. is moving in the wrong direction."

In particular, available data show that maternal mortality is highest among minority populations, according to Barbara Levy, MD, ACOG's vice-president for health policy. "If you're an African American woman in some parts of this country, your maternal mortality rate with pregnancy is higher than it is in some countries in Sub-Saharan Africa and South Asia. If you're an African American woman in Washington, DC, your maternal mortality rate is somewhere north of 70 times what it is if you're a white woman."

"These are tough issues," she continued. "This is not straightforward."

Morbidity Also an Issue

And it's not just maternal deaths that are concerning, said Elizabeth Howell, MD, MPP, vice-chair of research at the Icahn School of Medicine at Mount Sinai Hospital, in New York City.

"For every maternal death, over 100 women experience severe obstetric morbidity or a life-threatening diagnosis, or [have to undergo a] lifesaving procedure during their delivery hospitalization," said Howell, who is also chair of ACOG's Workgroup on Reduction of Peripartum Racial Disparities. "It impacts nearly 60,000 women annually in the U.S., and rates are rising."

More data are needed if people want to address these issues, said MacDorman, who was the lead author of a study on maternal death rates published in the September issue of Obstetrics & Gynecology. She noted that studies from the 1980s and 1990s have suggested that there has been "significant underreporting" of maternal deaths.

"To improve reporting, a pregnancy question was added to the U.S. standard death certificate in 2003 -- the question asked if the [deceased] woman was pregnant at the time of her death, or within 42 days or 1 year before death," she explained. "However, there were delays in states adopting the new pregnancy question -- some states used their own questions that were different ... while other states had no question at all."

Because of these and other problems, "the U.S. has not published an official maternal mortality rate since 2007," MacDorman said. "This has created a deficit of information at a time when greater attention is focused on maternal mortality than ever before."

Texas an Outlier

MacDorman and colleagues found that the maternal mortality rate was much higher in Texas than in any other state; in fact, the rate there increased from 18.6 per 100,000 live births in 2010 to 38.6 in 2012. "It's very rare to see a doubling in a 2-year period," she said. Interviews with federal and state health officials "didn't identify any processing or coding changes" that could account for the jump.

She added that "the maternal mortality increase coincided with large cuts in women's health programs and the closing of clinics throughout the state. It's certainly interesting that these two things happened at the same time. However, since my study was based on the death certificates, which had limited information on them, I am not able to establish a direct connection."

In the meantime, "there are a lot of things we as providers can do to change the outcomes" leading to maternal morbidity and mortality, said Levy. "And a particular one we can address -- preeclampsia and obstetric hemorrhage -- is where we can move the needle and change outcomes for women."

Howell discussed the work of the Alliance for Innovation on Maternal Health, a group that has a "unique perspective because it's putting disparities under a safety umbrella -- raising awareness among health systems, departments of health, and clinicians who care for pregnant women." The alliance includes a group of experts from diverse fields, including family physicians, ob/gyns, maternal/fetal medicine physicians, and public health professionals and nurses, she explained.

Maternal Mortality 'Bundle'

The group has developed a "bundle," or toolkit, aimed at reducing disparities in peripartum morbidity and mortality. "The bundle highlights shared decision-making, implicit bias, and continuity of care," Howell continued. "It also stresses the importance of education -- for providers and patients, but also for the staff and all members of the hospitals, around these issues of disparities ... We give specific recommendations to address care fragmentation.

"We know that nearly half of severe events and maternal mortality are preventable, that hospital quality is an important and contributing factor; there's also growing evidence that the use of interventions improves outcomes in this setting, and our goal is that this bundle will be used by hospitals, healthcare systems, and others as one of many essential steps to reduce disparities."

The alliance also recommends that health systems implement a "disparities dashboard" in which they measure quality metrics, stratify the results by race and ethnicity, identify gaps, and launch quality improvement projects to address the gaps. Particular effort was made to make the bundle "feasible in all types of systems and careful about making sure many recommendations are feasible in low-resourced settings," she added.

Similar efforts are taking place within the state of California, according to Elliott Main, MD, medical director of the California Maternal Quality Care Collaborative. "The state convened the first-ever maternal mortality review committee," he said. The group, which Main chaired, "did find a series of clearly preventive deaths -- [including from] hemorrhage and preeclampsia -- there were clear opportunities to prevent those cases." The group put together quality improvement toolkits that included best practices and a series of sample policies and procedures and information about how to implement them in hospitals, and ran them through statewide learning collaboratives.

Through a federally funded project in collaboration with the Council on Patient Safety in Women's Health Care -- a group that includes ACOG, the American College of Nurse-Midwives, and other organizations -- experts have developed safety bundles for hemorrhage, severe preeclampsia, severe hypertension, prevention of blood clots, and safe reduction in primary Cesarean sections, "which is a significant cause of morbidity," Main said.

"But it's one thing to have a bundle ... Then you have to implement it," he added. "For that, we have the Alliance for Innovation on Maternal Health ... which is working with states to move this forward." More statewide collaboratives are being set up -- so far, 10 states are involved, with others interested in coming on board.

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